Knowledge, attitudes, and practices among patients with combined dentition defect and non-functional impacted teeth toward tooth autotransplantation

Background Tooth autotransplantation (TAT) is a surgical procedure involving the extraction of a tooth from one location and its subsequent transplantation into another alveolar socket within the same individual. This innovative treatment approach holds significant promise. Nonetheless, the potential recipients exhibit a limited level of awareness and understanding of this procedure. This study investigated the knowledge, attitudes, and practices (KAP) among patients with combined dentition defects and non-functional impacted teeth toward TAT. Methods This web-based cross-sectional study was conducted between December 2022 and February 2023 at one hospital. A self-designed questionnaire was developed to collect demographic information of the patients and assess their knowledge, attitudes, and practices toward TAT. Results A total of 533 valid questionnaires were collected. The mean knowledge, attitude, and practice scores were 5.55 ± 2.38 (possible range: 0–10), 26.82 ± 2.46 (possible range, 8–40), and 27.45 ± 7.40 (possible range, 9–45), respectively. Conclusion The participants had insufficient knowledge, negative attitudes, and passive practices toward TAT. Targeted interventions should be implemented to improve the understanding and practice of TAT among patients with dentition defects. Supplementary Information The online version contains supplementary material available at 10.1186/s12903-024-04545-7.


Background
Dentition defects, including partial tooth loss, lead to abnormal tooth alignment [1].Such defects can adversely impact patients' pronunciation, masticatory function, aesthetic appearance, and overall health of their oral and maxillofacial systems [2].Tooth autotransplantation (TAT) is a surgical procedure that involves extracting a tooth from one location and transplanting it into another alveolar socket within the same individual.This technique is commonly used for relocating impacted, unerupted, misplaced, or ectopically erupted teeth or in cases involving missing teeth requiring extraction [3,4].TAT offers several advantages, including facilitation of implant movement with adjacent teeth, promotion of bone regeneration in the surrounding area, good biocompatibility, cost-effectiveness, and short treatment duration [5][6][7].Considering the benefits, TAT may serve as an effective strategy to overcome the limitations associated with traditional dental defect treatments.It is essential for the general population to be aware of this intervention's potential.
Previous studies have evaluated the knowledge, attitudes, and practices (KAP) of TAT among residents specializing in oral and maxillofacial surgery (OMFS) and pediatric dentistry [8,9].These studies revealed that OMFS residents demonstrated insufficient knowledge concerning TAT.Since healthcare providers are a primary source of health-related information, it is crucial to incorporate TAT into the dental curriculum and standard OMFS textbooks to address this gap.In addition, practical training during the post-graduation period should be provided.Although most pediatric dentists are familiar with the TAT procedure, they have limited practical experience due to inadequate training.Moreover, several studies have identified that conducting KAP surveys can help identify gaps, misunderstandings, misconceptions, and deficiencies concerning autogenous dental implants within these three dimensions [10][11][12].Nevertheless, no published studies or surveys assessed the KAP toward TAT among patients with combined dentition defects and non-functional impacted teeth.
Therefore, this study aimed to assess the KAP toward TAT in this population.The findings could contribute to developing educational interventions to enhance the general population's KAP regarding TAT.

Study design and participants
This web-based cross-sectional study was conducted between December 1st, 2022, and February 18th, 2023, at one hospital among patients with combined dentition defects and non-functional impacted teeth.A selfdesigned questionnaire was developed to collect the demographic information of the patients and assess their KAP toward TAT.The study included participants who met the following criteria: (1) age between 18 and 45 years old, (2) presence of dentition defect requiring repair, and (3) presence of non-functional impacted teeth.Questionnaires containing blank items or logically flawed responses were excluded from this study.This study was ethically approved by the Ethics Committee of the First Affiliated Hospital of Xi'an Jiaotong University (ethical approval No. XJTU1AF2023LSK-326), and informed consent was obtained from the participants.

Questionnaire introduction and collection
The questionnaire was developed with guidance from the Chinese Expert Consensus on Standardized Procedures for Tooth Autotransplantation [13] and the relevant literature [5,14].It was further modified based on feedback from three senior experts (Dr.Tao Hong, Chief Physician in Oral Implantology with 38 years of experience; Dr. Liu Xiuli, Associate Chief Physician in Prosthodontics with 40 years of experience; and Dr. Wang Xuerong, Associate Chief Physician in Oral and Maxillofacial Surgery with 42 years of experience.) and then pilot-tested on a small scale (n = 53), with a Cronbach's α coefficient of 0.855, indicating good internal consistency.
The final questionnaire was in Chinese and contained four dimensions: demographic information, knowledge, attitudes, and practices.The demographic information consisted of 14 items, while the knowledge, attitudes, and practices comprised 11, eight, and nine items, respectively.The knowledge items were scored 1 point for correct answers and 0 points for incorrect answers.Two logically contradictory trap questions, namely "Dentition defects may have an effect on the individual's pronunciation" (K3) and "The dentition defect does not have any effect on the individual's pronunciation" (K10), were excluded from statistical analysis, resulting in a possible score range of 0 to 9. The attitude and practice items scored on a 5-point Likert scale ranging from very positive (5 points) to very negative (1 point).The possible score ranges were 8 to 40 for attitudes and 9 to 45 for practices.Data collection was performed using an online questionnaire hosted on Sojump (http://www.sojump.com).
The participants were recruited through convenience sampling when they presented to the hospital for a consultation.The online questionnaire was disseminated to the study participants through popular social media platforms such as WeChat.The participants simply had to log into the questionnaire, read and sign the informed consent form, and complete the questionnaire.

Statistical analysis
The sample size was calculated using the formula where Z 1−α/2 equals 1.96, δ is the allowable margin of error, usually set to 0.05, and p is set to 0.5 since the value is maximized when p = 0.5.Therefore, the sample size for the survey should be about 384 participants.Allowing for a questionnaire recovery rate of 80%, 480 questionnaires should be distributed.
STATA 17.0 (Stata Corporation, College Station, TX, USA) was used for statistical analysis.The continuous variables were expressed as means ± standard deviations.The categorical variables were expressed as n (%).The continuous variables that conformed to a normal distribution were tested using Student's t-test or ANOVA.Participants who scored in the top 75% were deemed to possess sufficient knowledge, positive attitudes, and proactive practices.Multivariable logistic regression analysis was used to identify the risk factors for KAP.The cutoff scores for sufficient knowledge, active attitudes, and proactive practices were set at 8, 28, and 32, respectively.Two-sided P < 0.05 was considered statistically significant.
In the knowledge dimension, the question that exhibited the highest accuracy rate (89.68%) was about the impact of dentition defects on an individual's pronunciation (K3).Conversely, the question with the lowest accuracy rate (45.78%) revolved around TAT, which encompasses the surgical relocation of a tooth within the same individual.Remarkably, this procedure allows the use of any tooth, such as a transplanted one, and lacks specific indications (K5).Furthermore, the correctness rate for the statement "Tooth autotransplantation can be performed even if the patient has a severe metabolic bone disease" (K11) was low, at 51.97% (Table 2).
Regarding attitudes, over 80% of respondents strongly agree or agree that acquiring knowledge about dental abnormalities and their corresponding treatments is important (A1).About 87% of them also agree in terms of adhering to doctor's instructions, timely medication intake, and maintaining attention towards prognosis (A3) and the idea of communicating with their doctors regarding their conditions (A2).Approximately 79% of them exhibited confidence in the treatment options selected by their doctors (A6).Moreover, the responses for A4, A5, and A7 indicated that over 70% of the respondents recognize the benefits of employing TAT in MRI and CT examinations (A4), albeit expressing concerns about the possibility of post-operative teeth loosening (A5) and procedure failure (A7).Approximately 67% of the respondents strongly agree or agree that the decision to choose TAT is primarily influenced by economic considerations (A8) (Table 3).
The results from the practices revealed that more than 40% of the respondents expressed a higher level of concern regarding metabolic-related bone diseases (P6), and over 60% were willing to recommend TAT to others facing the same condition as themselves (P9).Additionally, over 70% of the participants maintained good oral health and practiced proper oral hygiene routines 3-4 or 5-6 times per week in their daily lives (P7).Moreover, more than 60% of the respondents were open to considering TAT as a viable treatment option (P8).However, only approximately 30% of the participants consistently or frequently visited a dental clinic or hospital dentist for regular dental checkups (P1), received regular professional dental care (P2), actively sought knowledge about dental abnormalities and TAT (P3), and expressed concern about tooth misalignment (P4) or periodontal disease (P5) (Table 4).

Discussion
The participants had insufficient knowledge, negative attitudes, and passive practices toward TAT.Targeted interventions should be implemented to improve the understanding and practice of TAT among patients with dentition defects.Previous studies have explored the knowledge, attitudes, and practices toward TAT among dentists and have reported inadequate understanding and practice [8,9,15].However, there is a lack of studies focusing on patients.
In this study, it was found that patients had insufficient knowledge of TAT.In order to bridge this knowledge gap, targeted education should be provided to enhance patients' understanding of TAT indications [3,6,16].Moreover, the multivariable analysis revealed that participants with dental defects caused by periodontal disease and caries exhibited better knowledge compared to those with defects resulting from external trauma.This discrepancy may be attributed to the regular hospital visits of patients with periodontal disease and caries, which could motivate them to learn about dentistry, including TAT and dental defects [17].In addition, a history of bleeding gums or sore teeth was another factor influencing the knowledge scores.As bleeding gums or sore teeth are common symptoms of dental diseases, individuals who have experienced these symptoms may have greater exposure to dental knowledge [18,19].
Regarding attitudes, a considerable portion of the participants expressed concerns about surgical failure and complications despite preferring the benefits of TAT in MRI and CT examinations.Thus, dentists must meticulously assess the indications for a given procedure, considering patient selection and the condition of immature teeth [20].Fortunately, most participants expressed strong agreement or agreement regarding the significance of acquiring knowledge about dental anomalies and their corresponding treatments.They emphasized the importance of diligently adhering to doctors' instructions, ensuring timely medication intake, and displaying attentiveness toward prognosis.Moreover, many participants demonstrated a willingness to communicate openly with their healthcare providers regarding their specific conditions, exhibiting a sense of trust in the treatment options recommended by the doctors.In terms of practices, the average scores for practices were substandard, indicating insufficient adherence to proper oral health habits by the participants.Only about 30% of the participants frequently visited dental clinics or hospital dentists for regular dental checkups, received regular professional dental care, proactively sought knowledge about dentition defects and TAT, and expressed concerns about tooth deformity or periodontitis.Several studies have also demonstrated suboptimal oral health management practices among various populations [21,22].Although many people prioritize maintaining oral health habits, only a small percentage undergo regular dental checkups and receive dental care [23].Educational interventions conducted by healthcare professionals in their practice settings have the potential to address this issue [24][25][26].More than 60% of the participants in this study expressed willingness to choose TAT as a treatment option and recommend it to others with similar conditions, indicating a positive acceptance of the procedure.It may be attributed to the fact that TAT uses natural teeth to restore missing teeth, aligning with patients' treatment expectations [27].
This study retains significant clinical relevance as it highlights several issues about TAT, including inadequate knowledge, negative attitudes, and passive engagement.These findings serve as a crucial reminder to healthcare professionals about the importance of customizing interventions based on patient's requirements.Healthcare providers can enhance patients' comprehension of the subject by delivering targeted education and information about TAT, fostering positive attitudes, and elevating their practical proficiency.
This study has several limitations.As a cross-sectional study, it is unable to establish causal relationships.The results rely on self-reported questionnaires, which may be influenced by recall bias and a desire to present their clinical knowledge and experience positively.The participants were from a single hospital and a limited geographical area, limiting generalizability.

Conclusion
In conclusion, the participants had insufficient knowledge, negative attitudes, and passive practices toward TAT.Targeted interventions should be implemented to improve the understanding and practice of TAT among patients with dentition defects.

Table 1
Demographic characteristics and KAP score

Table 2 KnowledgeTable 3 Attitudes
Your choice of tooth autotransplantation is more of an economic consideration, and you may prefer a treatment option other than tooth autotransplantation if you are in a better financial state.